HemoDoc, From Doctor to Patient

Do You Know Your Ultrafiltration Rate (UFR)?

By Peter Laird, MD

Dialysis patients know their monthly hemoglobin levels, albumen, phosphorus, potassium and Kt/V but today, ultrafiltration rates are not published for the patients to review and understand. Sadly, excessive ultrafiltration rates are one of the major sources of morbidity and mortality for dialysis patients, yet CMS does not require dialysis units to report these figures to patients. Many recent studies articulate the risks of taking off too much fluid too rapidly leading to myocardial ischemia and stunning.

Fluid Removal During Dialysis and Cardiovascular Mortality: Results

 

Associations between UFR and All-cause and CV Mortality

Overall, 871 deaths occurred during 5,233 patient-years of at-risk time; 343 of these deaths were due to CV causes. The median survival time was 2.5 years. Compared with UFR ≤10 ml/h/kg, UFR >13 ml/h/kg was significantly associated with all-cause mortality: unadjusted hazard ratio (HR) (95% confidence interval (CI)) 1.20 (1.03–1.41) (Figure 1). When multivariable adjustment was used to account for baseline differences between groups, this association was greatly potentiated: HR (95% CI) 1.59 (1.29–1.96). UFR 10–13 ml/h/kg bore an intermediate association with CV mortality that was not statistically significant: adjusted HR (95% CI) 1.06 (0.87–1.28). Results were similar when UFRs following the long interdialytic break were excluded from consideration, when the referent group was restricted to participants with UFR 8–10 ml/h/kg (data not shown), and when flux and Kt/V treatment group assignments were included as covariates in the statistical model (Supplementary Table SA online).

The effect on mortality of ultrafiltration rates increase dramatically once it is above 10 ml/hour/kg. The calculation is quite easy to do. Using an example of a dialysis patient who weighs 70 kg, dialysis for 4 hours and takes off 2 liters of fluid, we have: 2000 ml/4hr/70 kg = 7.14 ml/hr/kg. However, if we look at a 70 kg patient who dialysis for 3 hours taking off 3 L of fluid, the calculation changes drastically: 3000 ml/3hr/70 kg = 14.3 ml/hr/kg. Shortening the dialysis time and increasing the amount of fluid taken off with ultrafiltration now places the patient in a higher risk of cardiac and all cause mortality.

Secondary Analysis

In order to more fully examine the threshold(s) at which UFR may become harmful, we
conducted analyses in which we examined the association of UFR, represented as a cubic spline, with CV and all-cause mortality. As demonstrated in Figure 3, the HRs for both CV and all-cause mortality rose sharply at values between 10 and 14 ml/h/kg, and to a less pronounced degree at higher values. Consistent with results of the primary analysis, the HR for CV mortality was greater than that for all-cause mortality at all values of UFR.

Just as all dialysis patients receive a monthly report showing URR, Kt/V, Alb, Potassium, Phosphorus and Hemoglobin levels, I believe that the UFR should be a monthly reported matrix as well that should also be tied into the QIP measures. After all, having normal labs and an "adequate" Kt/V and normal URR are meaningless if the patient undergoes concurrent dialysis sessions with excessive ultrafiltration rates that patients can easily calculate for themselves in the comfort of their own homes. I was speaking with Rich Berkowitz earlier today about this issue and he decided to develop a UFR calculator which he has posted on Home Dialyzors United:

 UFR and CV and ALL Cause Mortality Adjusted Hazard Ratio Calculator

Research has proven there is a definite relationship between how much fluid is removed per hour per kilogram of weight.  This simple calculation will allow you to easily see how you compare to the Adjusted Hazard Ratio per the graph below.  You can link to the specific Kidney International research paper HERE.

If your ultrafiltration rates exceed 10 ml/hr/kg, then please discuss these issues with your medical team on how you can avoid excessive risk of cardiovascular and all cause mortality. In addition, if you have an excessively high untrafiltration rate, you are most likely also at risk of feeling nauseous, vomiting, experiencing severe leg cramps and at risk of passing out during dialysis. In addition, if your ultrafiltration rate is high, many nephrologists will place you on a "sodium modeling program" where they add salt to your cleansing fluids that most patients retain after dialysis leading to severe thirst and headaches. In many ways, excessive ultrafiltration rates not only increase your risk of death, they also add greatly to the burden of symptoms associated with dialysis. 

There is a better way to do dialysis and it all starts with longer, slower and gentler dialysis regimens. Short, fast and violent dialysis sessions leave patients feeling drained and at increased risk of heart attacks, chronic damage to the heart and severe discomfort during dialysis. The simple answer is to reduce ultrafiltration rates so that they don't exceed 10 ml/hr/kg. This simple calculation could save your life and make your dialysis sessions easier to tolerate. If your UFR is elevated, you may want to discuss the issues in the Medscape article and consider modifying your dialysis prescription or consider home hemodialysis where daily treatments or nocturnal almost completely eliminate this problem.

The Kjellstrand Lecture: The Deadly Delay - Part IV: Survival

By Peter Laird, MD

Since the advent of hemodialysis with the Scribner Shunt in 1960, chronic hemodialysis became the most widely utilized renal replacement therapy which is still true until today. Prior to the ESRD program in 1973, dialysis survival rates were substantially higher than today as noted by Edmund G. Lowrie in a NEJM article on transplant and dialysis survival rates:

Survival of Patients Undergoing Chronic Hemodialysis and Renal
Transplantation

Over an eight-year period 172 patients received an allograft from a living, related donor, 112 received cadaveric transplants, and 125 were placed on home dialysis. In a period of three years, 287 patients passed through our center dialysis program. Analysis of survival curves shows that patient survival was significantly better in recipients of transplants from living, related donors and in dialysis patients than in those receiving a cadaver graft. One-year patient survival rates for recipients of parental, sibling and cadaver allografts were 84.2, 89.5 and 68.7 per cent respectively. Survival rates at one and two years for home-dialysis patients were 88.5 and 77.8 per cent, and similar values for center patients were 92.9 and 86.1 per cent. These probabilities should be considered in the choice of which form of therapy to employ in a given patient, and illustrate the need for continued investigation into the prevention of allograft rejection and cadaver-recipient selection, (N Engl J Med 288:863–867, 1973)

Presented in part at the Fifth International Congress of Nephrology, Mexico City, Mexico, October 8–13, 1972.

Survival rates prior to the ESRD program were on the average of around 10% annual mortality in many centers around this nation; the equivalent of the annual Japanese dialysis population today. However, since the NCDS instituted urea kinetics as the standard of care in the early 1980's and shorter and more violent dialysis sessions became the norm in America, annual mortality rates have more than doubled and have hovered around 22% as they are today with no significant improvement in the last twenty years. Many fail to realize that the five year survival for dialysis patients is worse than many of our most dreaded cancers and other ailments.

Sadly, the American nephrology community as a whole has ignored the pioneering work of Scribner and his colleagues for nearly three decades as preventable deaths soared. Many fail to remember that Dr. Lowrie recorded annual mortality as low as 7% in 1972 as the gold standard renal replacement therapy, even better than renal transplant at that time. Beginning in the 1990's with the investigation of daily, nocturnal home hemodialysis by Uldall and Pierratos, short daily and nocturnal dialysis modalities have shown significant survival benefit in line with the original survival in the 1960's and early 1970's.

Today, we have several well done observation studies following patients on daily dialysis for several years. These results are not center specific and have been duplicated in the United States, Australia and Canada. Dr. Carl Kjellstrand has supported daily dialysis for nearly forty years while instead, his colleagues adopted shorter and shorter dialysis sessions supported by the measurement of urea kinetics.

After all, the randomized and controlled trial, the NCDS had "proven" that the length of a dialysis session as measured in "TIME" had no statistically significant correlation with outcomes. Amazingly, the NCDS is still quoted widely by dialysis experts debating the outcomes of these observational studies yet fail to question why the dialysis outcomes forty years ago with inferior equipment, inferior knowledge of secondary morbidity associated with dialysis and inferior pharmaceutical support had paradoxically far superior outcomes.

Just as in 1973, without the benefit of randomized and controlled trials, the standard of comparison for the effectiveness of the renal replacement therapies was a direct comparison between the modalities.  Just as in 1973, dialysis and renal transplant which by the way has NEVER had a single randomized and controlled trial compared to dialysis outcomes is one measure of renal replacement therapy that does give comparative meaningful values.  Dr. Kjellstrand compared his own short daily dialysis studies with over twenty years of data to the USRDS in-center PD and HD patients as well as the renal transplant revealing equal survival with the daily dialysis options.

In 2009, Pauly, et al likewise utilized the measuring stick of transplant survival and compared their results directly to the average survival of living donor transplant and cadaveric transplants. Despite the number of earlier studies showing equal results as well as the original outcomes all the way back to the time of Dr. Lowrie's 1973 article with 7% annual mortality, many continue to question the validity of Dr. Pauly's results since they are observational in nature and not from a randomized and controlled trial.

After fifty years of data collection, the American nephrology community remains in a catatonic state paralyzed by indecision on what is the basic and standard dialysis dosage. Urea kinetics has brainwashed the American nephrologist into an altered state of consciousness in blissful ignorance of the damage done to millions of patients by poorly conducted and openly accepted randomized and controlled trials including the HEMO study which simply asked the wrong question: is a higher Kt/V the answer for survival. They likewise never question the lack of RCT studies proving thrice weekly, 3-4 hour treatments against the standard of thrice weekly 6-8 hour treatments.

The American nephrologist is religiously vested in the irrational belief that urea removal has clinical importance when we know that higher blood flows, higher ultrafiltration rates, high flux kidneys and other factors which completely ignore the underlying "unphysiology" of dialysis can all be manipulated to "improve" urea kinetics while at the same time our average annual survival is double the rate prior to the introduction of urea kinetics in the 1970's and early 1980's especially after the NCDS.

The early pioneers utlized very simple clinical monitors of how "adequate" the dialysis was for an individual patient, that of survival and rehabilitation. If the patient didn't feel well enough to return to work and a have viable life, the pioneers of dialysis simply increased their dosage in time on dialysis. That is how they derived the minimum standard dosage of thrice weekly 6-8 hour sessions most of which were done at home ovenight.

Now, a year and a half after the publication of the FHN short daily dialysis study, all that the American nephrologist can offer as advice is that we need larger and clearer endpoints in another randomized and controlled trial looking at mortality. Certainly ASN and the RPA have not in any manner stated that the standard of care for all dialysis patients should be daily dialysis with the best results from NHHD. Some illogically utilize the known results of the "killer" weekend to suggest we have equipoise, the genuine uncertainty over whether a treatment will be beneficial, to justify such a study. It appears that they are the only group that believes we have clinical uncertainty in daily dialysis. They have certainly forgotten that the NEJM and Dr. Lowrie used dialysis outcomes as the gold standard to compare mortality to renal transplant with dialysis outcomes better in those days, double the survival of transplant in its early years. We now have double the survival with transplant, but only if we don't compare it directly to optimal dialysis strategies that return us to the historical mortality rate noted by Lowrie in 1972.  A short memory of the history of dialysis is in many ways our worst enemy of the truth.

In 2001, those that supported the FHN promised it would be the arbiter of these questions. Although the short daily dialysis study did offer up a positive result, many American nephrologists reject its conclusions based on the coprimary outcomes that do not differentiate the contributions of death and LVMI separately for individual analysis, thus rendering its positive outcomes wasted. Likewise, the failed recruitment and changes to the exclusion criteria of the nocturnal study leave us without any direct conclusions from the FHN nocturnal arm. After ten years of a deadly delay, the FHN has not lived up to its promise and the American nephrology community remains unconvinced. At this point, I am not sure that CMS or the American academic nephrology community will ever be convinced. Instead, it will be the market place and patient demand that turn the tide on the economics of daily dialysis that will lead to a rebound of optimal therapy.

Hopefully, the American nephrologist will return to the patient and ask the simple questions that Dr. Scribner and his colleagues asked? How do you feel? Can you work? Have we restored your life? Until those simple questions once again become the measure of adequacy, the mental masturbation of making the nephrologist feel good about the patient's Kt/V while the patients life paradoxically slips away may one day come to an end. We can only hope that we avoid any further deadly delays.

Slides courtesy of Dr. Carl Kjellstrand.

The Kjellstrand Lecture: The Deadly Delay - Part III: The Killer Weekend

By Peter Laird, MD

The NEJM recently published a widely acclaimed study on the elevated death rates of 32,065 hemodialysis patients on Monday and Tuesday after the long "killer weekend." This is considered one of the most important medical studies in the field of nephrology in 2011. The Renal Fellow Network does an annual survey on the most important clinical developments each year and then publishes the results in a top ten posting. This year, the NEJM elevated mortality with the long interdialytic interval article was rated as the third most important study in 2011. (here)

Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis

BACKGROUND: Patients with end-stage renal disease requiring dialysis have limited tolerance of metabolic and volume-related deviations from normal ranges; in addition, the prevalence of cardiovascular disease is high among such patients. Given these problems, we hypothesized that a long interdialytic interval is associated with adverse events in patients receiving hemodialysis.

CONCLUSIONS: The long (2-day) interdialytic interval is a time of heightened risk among patients receiving hemodialysis. (Funded by the National Institutes of Health.)

However, these were not new and groundbreaking results. The issue of increased deaths with the long interdialytic interval is a well known phenomenon that has been ignored by nephrology for more than a decade. A.J. Bleyer et al, studied the records of 375,482 dialysis patient deaths in the USRDS from 1977 to 1997, a twenty year study period. This study showed direct evidence of an increased risk of death from hemodialyis after the long interdialytic interval which was not found in PD patients.  PD patients deaths are evenly distributed  among each day of the week. Likewise, non cardiac deaths in hemodialysis patients are not elevated on Monday or Tuesday.

Sudden and cardiac death rates in hemodialysis patients

The results from the entire USRDS database indicated a nonrandom distribution of cardiac deaths for HD patients. Figures 1 and 2 demonstrate that although cardiac and noncardiac deaths for PD patients are rather evenly distributed throughout the week, cardiac deaths in HD patients occur most frequently on Monday, with the next most common day of death being Tuesday. In addition, noncardiac deaths for HD patients are evenly distributed throughout the week.

Data from the CMAS were then used to identify the most likely dialysis schedule. MWF HD patients were much more likely to die a cardiac death on Monday than other days of the week. Wednesday and Friday—the other dialysis days—were the next most common days of cardiac death. Deaths from noncardiac causes were evenly distributed. Patients on a TTS dialysis schedule were more likely to die from a cardiac cause on Tuesday than other days, although these changes were not as prominent.

A second study by Karnik, et al in 2001 confirmed these results among a study group of more than 77,000 patients.

Cardiac arrest and sudden death in dialysis units.

BACKGROUND: For patients with end-stage renal disease and their providers, dialysis unit-based cardiac arrest is the most feared complication of hemodialysis. However, relatively little is known regarding its frequency or epidemiology, or whether a fraction of these events could be prevented.

METHODS: To explore clinical correlates of dialysis unit-based cardiac arrest, 400 reported arrests over a nine-month period from October 1998 through June 1999 were reviewed in detail. Clinical characteristics of patients who suffered cardiac arrest were compared with a nationally representative cohort of> 77,000 hemodialysis patients dialyzed at Fresenius Medical Care North America-affiliated facilities.

In my opinion, the most astounding revelation of the NEJM long interdialytic article of 2011 is that there has not been any change in therapy since two much larger studies were published over a decade prior to its publication showing exactly the same results. Mortality among American dialysis patients has flatlined for over twenty years as more and more patients flatline more often on Monday and Tuesday from preventable cardiac deaths.  It has puzzled me greatly why this NEJM article made such headline news around the world and fostered surveys declaring this "news" the third most important clinical study of 2011 when in many ways, it was inferior to the prior studies in terms of patient numbers and years of study.

Perhaps we will never know the impetus behind this study and the inordinate attention it received, but we do know that in the year of the bundle going into effect, this study has led many to recommend PD more often instead of looking at alternative HD modalities such as every other day dialysis and daily dialysis. The cost differential for PD vs daily HD points to PD as the most "cost effective" therapies if only considering clinic expenses alone. However, if you consider survival and total patient expenditures including hospitalization and pharmaceuticals, daily HD is the most cost effective and best survival strategy for dialysis patients with PD having equal survival to in-center conventional hemodialysis. (here)

Dr Kjellstrand calculated the number of lives in the last ten years from 2001 to 2011 that could have been saved from what we knew then on the long dialysis weekend excessive deaths. During the time that the FHN study was conceived, planned, implemented and reported, over 10,400 lives a year could have been saved instead of waiting ten years for the publication of the FHN and the long interdialytic weekend mortality studies, both in the NEJM. Sadly, despite all of these studies on the long killer weekend, the best that the academic nephrologists can recommend with confidence to America is that we need to study this issue further before making a commitment to more frequent hemodialysis schedules. How many more years will we see over 10,000 patients needlessly lose their lives year after year after year. This is now a ten year debate that has yet to see any action to eliminate to date. When will we end the killer weekend?

Slides courtesy of Dr. Carl Kjellstrand.

What is the Expected Lifespan on Daily Nocturnal Dialysis

By Peter Laird, MD

Nocturnal dialysis became the standard of care early in the course of dialysis as Dr. Stanley Shaldon introduced it to Dr. Scribner in 1964. By the time the ESRD program came into existence in 1973, the majority of patients on dialysis, dialyzed at home, thrice weekly for 8-9 hours each session. Utilizing this schedule, the majority of dialysis patients continued to work and had less than 10% annual mortality. We then entered the era of for-profit dominated in-center dialysis where providers shortened the sessions by increasing the ultrafiltration rates as well as the advent of the high flux artificial kidneys.  Since that time, our mortality surpassed those of the other developed nations by a rate of 2.5 times that seen in Japan today. While renal transplant made great strides improving their outcomes, dialysis patients lagged behind in the crowded open ward dialysis clinics. However, one medical group in Tassin France led by Dr. Bernard Charra, a protege of Dr. Scribner, kept the original schedule continuously for the last 40 years with excellent outcomes:

Long Slow Hemodialysis

Long slow hemodialysis (3×8 hours/week) has been used in Tassin for 30 years without significant change in the method. It provides excellent results in terms of morbidity and mortality. The better survival than usually reported on shorter dialysis is mainly due to lower cardiovascular mortality. The nutritional state of the patient is good, as well as the correction of anemia with low doses of EPO. But the main feature concerns blood pressure; hypertension is very well controlled without need for antihypertensive medications. The gentle ultrafiltration provided by a long session time associated with a low salt diet and a moderate interdialytic weight gain allows for normalization of the extracellular fluid space in most patients (dry weight) without important intradialytic morbidity. This low salt diet has paradoxically been forgotten in recent years while shortened dialysis time renders it more necessary than ever.

In the early 1990's, the Toronto medical group led by Dr. Uldall and Dr. Pierratos revived the concept of nocturnal dialysis here in North America and took the next step of increasing not only the duration of dialysis, but  also the frequency of dialysis from 6-7 sessions per week, creating the first daily nocturnal dialysis program. The initial published reports astounded the renal community with normalized phosphorus levels, reduced dosages of Epogen and prolonged survival in these patients.

Nocturnal dialysis: three-year experience

There is evidence that high frequency, as well as long duration, hemodialysis provides better clinical outcomes. We developed nocturnal hemodialysis, a new innovative form of renal replacement therapy, which is performed six to seven nights per week for 8 to 10 h during sleep at home. Blood flow was set at 300 ml/min and dialysate flow at 100 ml/min. . . There was hemodynamic stability and significant subjective improvement in patient well being. Nightly Kt/V was 0.99. Weekly removal of phosphate was twice as high and beta2 microglobulin 4 times as high as conventional hemodialysis. All patients have discontinued their phosphate binders and have increased dietary phosphate and protein intake. BP control was achieved with fewer medications. . . Nocturnal hemodialysis represents the most efficient form of dialysis at low cost and should be considered as an option for patients who can be trained for home hemodialysis.

By the end of the decade, Dr. Lockridge in Virginia and Dr. Agar in Australia converted many of their patients to daily, nocturnal dialysis with the same magnitude of beneficial outcomes as seen in the original studies by Dr. Uldall and Pierratos. In 2009, Dr. Pauly and his colleagues gathered 177 nocturnal hemodialysis patients from two Canadian centers showing that this treatment had equal survival to cadaveric transplant patients:

Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients

Results. The total study population consisted of 177 NHD patients matched to 1062 DTX and LTX recipients (total 1239 patients) followed for a maximum of 12.4 years. During the follow-up period, the proportion of deaths among NHD, DTX and LTX patients was 14.7%, 14.3% and 8.5%, respectively (P = 0.006). We found no difference in the adjusted survival between NHD and DTX (HR 0.87, 95% CI 0.50–1.51; NHD reference group), while LTX survival was better (HR 0.51, 95% CI 0.28–0.91).

Conclusions. These results indicate that NHD and DTX survival is comparable, and suggest that this intensive dialysis modality may be a bridge to transplantation or even a suitable alternative in the absence of LTX in the current era of growing transplant waiting lists and organ shortage.

We have now returned full circle to the basic tenants of the pioneers of hemodialysis who gave increasing dosages at more frequent sessions each week until they rehabilitated their patients. When a patient regressed, they increased the time on dialysis until the patient improved again. Dr. Uldall and Pierratos took up where the pioneers had left off with long, gentle nocturnal treatments and completed what the early researchers were unable to complete due to lack of funds and available machines, they evaluated hemodialysis maximum duration and maximum frequency coupled together for the first time. The fact that survival with daily nocturnal dialysis is  now equivalent to cadaveric transplant survival opened the doors to optimal dialysis strategies throughout the world.

In truth, this is Dr. Scribner's vision completed, yet far too many patients in need of home hemodialysis and its proven benefits cannot overcome the many barriers to access this modality, not the least of which is the ponderously slow acceptance by the American nephrology community as well as many insurance companies. The expected lifespan of over 70% survival after 10 years of nocturnal home hemodialysis demands an answer to those unable to remove the barriers to care.  It is time to bring this lifesaving procedure the real full circle by now making it available to all capable patients who request it.

What is the Expected Lifespan on Short Daily Dialysis

By Peter Laird, MD

In-center conventional dialysis as practiced in America results in an average survival of about 40% over a five year period of time depending on which survey is looked at. The results of our rapid ultrafiltration rates and short treatment times thrice weekly is only a shadow of the original treatments times of 8-9 hours thrice weekly developed by the pioneers of dialysis. The survival of common cancers and even HIV are actually better than the outcomes of American style, in-center dialysis care.

Nearly 50 years later, the wisdom of longer duration or more frequent dialysis prevails. Many entering into the world of dialysis are confronted with the knowledge of our dreadful survival statistics and look for alternative treatment options. One such option that many choose is short daily hemodialysis in the comfort of their own homes, dialysis 5-7 days a week for 2-3.5 hours at a time.  The good news is that observational studies show excellent outcomes with this treatment option.

Short daily haemodialysis: survival in 415 pateints treated for 1006 patient-years

Results. Eighty-five patients (20%) died; 5-year cumulative survival was 68 ± 4.1% and 10-year survival was 42 ± 9%. Age, secondary renal failure and in-centre dialysis were associated with mortality, while gender, frequency of dialysis (5, 6 or 7 per week), continent, country and blood access were not. Survival was compared with matched patients from the USRDS 2005 Data Report using the standardized mortality ratio and cumulative survival curves. Both comparisons showed that the survival of the daily haemodialysis patients was 2–3 times higher and the predicted 50% survival time 2.3–10.9 years longer than that of the matched US haemodialysis patients. Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants.

Conclusions. Survival of patients on short daily haemodialysis was 2–3 times better than that of matched three times weekly haemodialysis patients reported by the USRDS.

Another cohort by Dr. Kjellstrand had even better outcomes than those in the study above in a prior study he published. Returning to optimal dialysis strategies as first practiced in America supplying patients with more frequent and longer duration dialysis breaks the cycle of death and suffering that in-center dialysis patients encounter today. While we have no true cures for ESRD, there is excellent data to promote the use of short daily dialysis over the conventional treatments. The Frequent Hemodialysis Network Trial Group followed their cohort of patients for 12 months likewise showing a significant benefit, yet we continue to fail to provide only a fraction of American patients optimal dialysis today. After 50 years of consistent efficacy, alternative treatment options should become the standard treatment offered to all eligible patients.

Short Daily Dialysis Can be Too Short

By Peter Laird, MD

The Frequent Hemodialysis Network Trial Group results published in November 2010 has focused many providers interest in short daily dialysis since the results of this randomized and controlled trial dramatically showed the benefits of short daily dialysis. The study endpoints of reduced LVH and improved physical-health composite score is a long awaited result from a randomized and controlled trial.  In addition, the long standing argument of how much dialysis and at what dose is best for patients stands on the side of the dozens of observational studies showing a benefit to more frequent and longer duration dialysis.  The gold standard of dialysis care is daily, nocturnal dialysis of 6-8 hours duration done at low blood flow and low ultrafiltration rates.

The NxStage System One portable home dialysis machine introduced a new wave of interest in home based therapies especially in the last five years.  Many now use the NxStage machine as short daily hemodialysis.  Combined with the ease of learning and using this system, patients are now free to dialyze in the comfort of their own home. However, many patients will be tempted to shorten their daily treatments to augment lifestyle changes and freedom.  Dr. Kjellstrand, et al published an important paper in September 2010 looking at the total weekly duration of dialysis and mortality. They found that sometimes, short daily dialysis can be too short:

Survival with short-daily hemodialysis: Association of time, site, and dose of dialysis

Short-daily hemodialysis can be too short. In this series of patients, every extra hour spent on dialysis was associated with better survival. This finding is in agreement with those of others analyzing thrice-weekly dialysis^5–8 and interestingly is seen even in patients treated by long night hemodialysis, where the weekly dialysis hours are 2 to 4 times longer than in our patients on SDHD.¹²

Patients considering home hemodialysis should bear in mind that time on dialysis correlates directly to survival.  For those considering short daily dialysis, avoiding total dialysis times less than 15 hours each week should be in the forefront of discussions with your medical team.  When coupled with the information of the FHN showing more frequent dialysis benefits, the optimal approach is to maximize time and frequency of sessions individualized to patients schedules and lifestyles.  We are once again coming full circle back to Dr. Scribner's wisdom of the Hemodialysis Product where he correlated survival based on a simple calculation of frequency and time on dialysis back in 2002.

How Long Can You Live on Dialysis?

By Peter Laird, MD

One of the most frequent questions people ask after the diagnosis of renal disease and impending failure is how long can a person live on dialysis.  The answer to that question in many ways depends on your zip code for Americans as Bill Peckham of DSEN is fond of stating. For many in America, unfortunately the outcomes of dialysis leads to a prognosis worse than many cancers and even HIV. Dr. Robert Lockridge has an excellent presentation at Home Dialysis Central (HDC)  (scroll down on HDC home page to the webinar) on informed consent that discusses the average lifespan of patients as part of his advocacy for nocturnal dialysis options.

Nevertheless, many patients have lived long lives on conventional incenter care.  A noted example is Barbara Rivers of Ocala Florida who recently celebrated 28 years of cumulative hemodialysis.

28 years of dialysis and still "percolating"

"I thank the Lord I'm still here," Barbara Rivers said as she received her kidney dialysis treatment Monday morning in Ocala, FL at the Ocala Kidney Group. Rivers receives dialysis every Monday, Wednesday and Friday for the past 24 years after her kidney transplant failed after 4 years after her surgery in 1982. Rivers was a substitute teacher and raised two children during her dialysis. Rivers received an award from the kidney group for her 28 years of dialysis, for the four years prior to her kidney transplant and 24 years after the transplant failed. 

“She is probably one of our best patients as far as attitude,” said nurse Heather Williams, who serves as lead administrator in the unit. Twenty-eight years on dialysis, she said, “is a great accomplishment because we've seen so many who do not even make it a year.”

He said Barbara has her good days and bad. “She knows her body,” he said. “She knows how the day is going to go, according to how she is feeling.”

He also pointed out that she does an extremely good job of watching her diet and fluid-intake and taking her medications.

The answer to how many years can a person live on dialysis is a complex one where every half hour more of dialysis per session improves outcomes with home nocturnal dialysis offering the best outcomes equal to cadaveric transplant,  normalized nutrition status, exercise, control of potassium and phosphorus improve outcomes, daily frequency of dialysis improves outcomes,  fistula for access improve outcomes, infection control and avoiding nosocomial infections reduces mortality, optimal anemia management and avoiding excessive ultrafiltration rates all impact positively survival.

The best answer to the question of the expected dialysis lifespan is answered by your own medical team that hopefully is an advocate of more frequent hemodialysis with proven outcomes as recently found in the Frequent Hemodialysis Network Trial Group.  Dialysis is only one of several excellent renal replacement options for chronic renal failure when applied in an optimal manner for the individual patient. As one noted researcher stated in the NxStageUsers first annual meeting, if your nephrologist doesn't support daily dialysis, find a different nephrologist.